Educational recommendations for the conduct, content and format of EULAR musculoskeletal ultrasound Teaching the Teachers Courses.

OBJECTIVE: To produce educational guidelines for the conduct, content and format of theoretical and practical teaching at EULAR musculoskeletal ultrasound (MSUS) Teaching the Teachers (TTT) Courses. METHODS: A Delphi-based procedure with 24 recommendations covering five main areas (Duration and place of the course; Faculty members; Content of the course; Evaluation of the teaching skills; TTT competency assessment) was distributed among a group of experts involved in MSUS teaching, in addition to an advisory educational expert being present. Consensus for each recommendation was considered achieved when the percentage of agreement was >75%. RESULTS: 21 of 24 invited participants responded to the first Delphi questionnaire (88% response rate). All 21 participants also responded to the second round. Agreement on 19 statements was obtained after two rounds. CONCLUSIONS: This project has led to the development of guidelines for the conduct, content and format of teaching at the EULAR MSUS TTT Courses that are organised annually, with the aim of training future teachers of EULAR MSUS Courses, EULAR Endorsed MSUS Courses, as well as national and local MSUS Courses. The presented work gives indications on how to homogenise the teaching at the MSUS TTT Courses, thus resolving current discrepancies in the field.

[Imaging of the shoulder]. / Imagerie de l'épaule.

Clinical history and patient examination are mandatory to correctly order shoulder imaging. The choice of the imaging modality will depend on different factors. Is the shoulder stable or instable? Was there a traumatic history or simply repetitive microtraumas? Is the A-C joint electively tender? Generally, plain X-rays is the first step in the shoulder imaging. However different views will be adapted to the clinical examination. Double oblique standard view in neutral position and rotations with associated profile is the basis of the examination. In the case of a painful stable shoulder, ultrasound is usually the second step. MRI is only necessary in case of deficient ultrasound. If surgery is an option, CT-scan or MRI without any contrast media are useful because ultrasound cannot correctly predict the eventual fatty degeneration of the muscles that contra-indicates the surgical treatment. In the case of shoulder instabilities, there is no place for ultrasound. The best choice is always an intra-articular injection of contrast medium followed by CT-scan or MRI. Only these examinations are able to depict labrum lesions or bicipital desinsertion. Finally, the AC joint must be evaluated separately from the rest of the shoulder with special radiological and ultrasound incidences. Stress or dynamic maneuvers can be added either with X-rays or ultrasound.

[Imaging of the spine: cost-efficiency]. / Imagerie de la colonne: coût-efficacité.

Despite the introduction 30 years ago of the CT scan and more recently of the MRI, the number of plain radiographs of the spine showed very little erosion during the last decade in Belgium. The reasons can be understood and found some good or false explanations. CT scanner is much more irradiating than plain radiographs. However it gives to the clinician much more relevant information considering the diagnosis and the medical outcome of the patient. MRI, which is equivalent to CT scan in terms of information, had, until now, very little access for the patients, with some delays up to 7 weeks. Moreover, the general idea in the perscriptor's mind and among the patients is that the price of the modern examinations (i.e. CT scan and MRI) are much higher than plain radiograph, which is in some way, correct, but perhaps in a smaller account than imagined. The precise indications of all these examinations have been published in 2004 either in Europe and Belgium. However the information about these guidelines among the general practitioners and specialists was not perfectly done. We will see that, by following these guidelines, a substantial drop off the prices can be obtained without decreasing the efficiency of the diagnostic tools and of the medical outcome of our patients.

[Sonography of muscles]. / Echographie des muscles.

Sonography constitutes a method of choice in the evaluation of muscular structures. Traumatic lesions represent the majority of muscular injuries. A good anatomical knowledge of the weakness sites, as well as knowledge of traumatic signs and symptoms is essential in order to deliver a precise report to the referring physician. Sonography may suggest other causes of muscle lesions, tumoral or dystrophic, before confirmation by MRI.

Ultrasound of muscles.

Muscles are among the soft tissues one of the best adapted to ultrasound examination. In fact, it was the first imaging available for the evaluation of muscle disease. The availability, low cost, and ease of examination makes ultrasound superior to MRI for follow-up of lesions and searching for healing problems such as as fibrosis, cystic haematomas, or myositis ossificans. When dealing with fresh traumatic muscle lesions, the main goal of ultrasound is to assess the presence of a muscle tear or not. Haematoma is the key sign of a muscle tear. The ideal time for the examination is between 2 and 48 h after the muscle trauma. Before 2 h, the haematoma is still in formation. After 48 h, the haematoma can be spread outside of the muscle. After healing, ultrasound can depict some complications such as a cystic lesion or myositis ossificans. Muscle atrophy, inflammation, avulsion and tumours are also good indications for ultrasound.

Ultrasound of the shoulder joint: non "rotator cuff" lesions.

Most of the papers in the literature are on rotator cuff lesions. This paper will deal with a somewhat forgotten part of the shoulder, the joint and the nontendinous structures around the joint. Since 1985, we have performed ultrasound examinations of the shoulder. We have collected many cases and some of them will be performed. The shoulder joint can be partly examined by ultrasound. We can get some information about joint effusions, humeral head cartilage, some part of the labrum, loose bodies, ganglions and fractures around the joint. The acromio-clavicular joint is also part of the examination, leading to diagnosis of sprains, osteoarthritis and dislocations. Non rotator cuff examination of the shoulder must be a routine part of the ultrasound examination of the shoulder.

[Ultrasonography of the wrist and the hand]. / Echographie du poignet et de la main.

There are six large groups of indications for sonographic study of the wrist and the hand: study of nerves, tendons, synovial cysts, ligaments and bony structures, diagnosis of Stener lesion, and search of pulley's abnormalities at the fingers. Use of high frequency probes as well as a gel-pad are required. The examination is essentially delicate, comparative and dynamic. Some structures such as small soft collections may disappear when the pressure of the probe is too heavy. An abnormality may become obvious only by comparison with the normal side, or appear only in a special position, such like synovial cysts. Recognition of osseous landmarks is essential, especially in the study of the wrist.

[Lesions of the anterior tibial tendon using ultrasonography: report of 2 cases]. / Lésions du tendon tibial anterieur enéchographie: rapport de deux cas.

Lesions of the tibial anterior tendon have been seldom described in the literature. To the best of our knowledge, no report analysing the diagnostic role of ultrasound as a diagnostic method has been published so far. Clinically, these lesions are regularly misdiagnosed as ganglions or even tumors. In the first case, ultrasound showed well known signs of tendon rupture as disorganization of the fibers, swelling, and presence of an anechoic zone corresponding to hematoma. In the second case, ultrasound showed an even more scarce lesion, i.e. insertion tendonitis on the medial cuneiform, sometimes misdiagnosed as a stress fracture. Once again, ultrasound is the method of choice, showing the spindle-like swelling characteristic of these lesions.

[Arteriography and treatment using angioplasty]. / Artériographie et traitement par angioplastie.

Renal angiography is certainly not the first examination to be done in case of hypertension. Its interest remains however high. It allows to demonstrate without doubt the reality of a significant stenosis. It can also be associated with a therapeutic procedure. The indications, with practical modalities, results and eventual complications are described below in two different parts: diagnostic and therapeutic.

[Future perspectives in medical imaging]. / Perspectives d'avenir en imagerie médicale.

Medical imaging, less than 105 years after the invention of X-rays in medicine, shows signs of extraordinary and almost exponential rise. Among the new techniques, the stress is laid on the last developments of echography like the imaging in three dimensions or the harmonic imaging. The helical scanner currently allows imaging in real time, from incredibly short times of acquisition and launches out in the virtual endoscopy. The MRI and particularly angio MR allows the visualization of small arterial or venous malformations as for soon the study of the coronary vessels with a reliability which will compete with the coronarography. The diagnostic angiography is undoubtedly destined for disappearing as of many other techniques which will be one day obsolete, or superfluous compared with such relevant and less invasive methods.

[The search for medical information on the World Wide Web]. / Recherche de l'information médicale sur le world wide web.

The internet has experienced tremendous growth over the past few years and has currently many resources in the field of medicine. However, many physicians remain unaware of how to gain access to this powerful tool. This article briefly describes the World Wide Web and its potential applications for physicians. The basics of web search engines and medical directories, as well as the use of advanced search with boolean operators are explained.

[Current methods in the diagnosis of deep venous thrombosis of the lower limbs]. / Les méthodes actuelles de diagnostic de la thrombose veineuse profonde des membres inférieurs.

The diagnosis of lower limb deep vein thrombosis requires to use of complementary diagnostic tests. For a long time phlebography has been the only reliable examination and is always regarded as the gold standard by many people. In recent years, non invasive diagnostic modalities have been developed. Most significantly scintigraphy, plethysmography, color Doppler ultrasound and MR imaging. MRI is as reliable as venography but, at the present time, it is time-consuming and far less available than the other modalities. Scintigraphy and plethysmography may be useful but are less accurate and yield a somewhat higher rate of false positive and negative examinations. Color Doppler ultrasound has proved its effectiveness and is currently recommended as the diagnostic modality of choice. Venography is still a significant diagnostic tool for questionable cases or for technically inadequate Doppler ultrasound examinations.

[Contribution of Doppler sonography in inflammatory pathology of the large bowels]. / Contribution de l'échographie Doppler dans la pathologie inflammatoire du tube digestif creux.

At the end of the eighties, Doppler equipment added to conventional ultrasonography a new dynamic dimension. On the basis of radiological (US, CT, barium studies), clinical, biological, surgical and/or pathological correlations in 30 cases, the following considerations were emphasized. In case of intestinal obstruction, viability of the obstructed segment is compromised when Doppler parietal flow remains undetectable. In Crohn's disease or ulcerative colitis, as well as in acute appendicitis, presence of Doppler parietal flow throughout the affected thickened segment indicates an acute condition; similarly, abnormally high mean portal velocity (30-48 cm/sec; normal: 15 +/- 7 cm/sec), and abnormally low resistive index in the superior mesenteric artery (0.58-0.78; normal: 0.908 = 0.026) are detected. In colonic diverticulitis, similar characteristics can be observed, but are subtle and usually predominant at the mesenteric side of the affected segment in moderate diverticulitis. These abnormal Doppler findings disappear with successful therapy.

[Strategy for the use of imaging in shoulder impingement syndrome]. / Stratégie d'emploi de l'imagerie dans le syndrome de l'épaule conflictuelle.

The authors try to define the relative place of conventional radiology, ultrasound, arthrography, computerized tomography and magnetic resonance imaging in the diagnosis of shoulder impingement syndrome. The above mentioned types of examinations are analysed and commented one by one with their respective advantages and drawbacks. A global approach is described at the end of this article.

[diagnostic ultrasonography of air in the portal venous system: apropos of a case of colonic radionecrosis and literature review]. / Diagnostic echographique d'air dans le systeme veineux portal: à propos d'un cas de nécrose colique radique et revue de la littérature.

We present a case of dramatic radiation enterocolitis inducing portal venous air diagnosed by Doppler sonography only. The sonographic pattern consisted of multiple irregular hyperechoic areas into the liver, with internal repetitive noisy bidirectional peaks superimposed on the usual continuous Doppler display of the portal flow. Although portal hyperechoic moving foci alone may reflect only slow portal velocity, they do not create any Doppler distortion as do moving bubbles. Portal air may have multiple causes such as abdominopelvic abscesses, sepsis, intestinal distension, fulminant hepatitis, cholangitis, cholecystitis, diabetic acidosis..., but mesenteric infarct, necrotic enterocolitis, and radiation enteritis are life-threatening conditions that have to be diagnosed as soon as possible. Although large quantities of portal air may be demonstrated on plain film of the abdomen or by computed tomography, Doppler sonography may detect smaller quantities, allowing earlier diagnosis of intestinal pathology requiring immediate surgical treatment. Therefore, Doppler sonography of the liver should be performed in any patient with acute abdominal pain or distension, especially if being treated by abdominal radiotherapy.

[Jaundice secondary to a metastasis of a malignant melanoma at the level of the common bile duct]. / Ictère secondaire à une métastase de mélanome malin au niveau de la voie biliaire principale.

A patient presenting with a malignant melanoma of the skin developed obstructive jaundice. Ultrasound examination of the upper abdomen revealed dilated bile ducts and the presence of a solid mass at the hilum level. There was no evidence of biliary lithiasis. The intraluminal location of the mass was confirmed by endoscopic cholangiography. Laparoscopy disclosed a 2 cm mass within the wall of the common bile duct. Pathological diagnosis was common bile duct wall metastasis from malignant melanoma.

[Echography of breast cancer: review of symptoms, ultrasonic-guided punctures]. / Echographie du cancer du sein: rappels sémiologiques, ponctions échoguidées.

The paper describes the different echographic signs of malignancy and the technique of fine needle biopsy. In a series of 220 successive cytoponctions, only one case of false negative was recorded.